Assignment of Benefits (Sample)
Please find the attached Assignment of Benefits. Before use, please ensure that your exact legal name is typed in the same provided.
- Click here to download in WORD format for free
- Click here to download in RTF format for free (this is a universal format).
- Click here to download in PDF format for free
This is part is very important- make sure you have an Assignment for each of the companies you treat under. For example, if you treat under Jon Smith Chiropractic Inc. (for adjustments) and Jon Smith Rehabilitation (for massage therapy) then you will need two Assignments, one for each company. Feel free to call my office if you aren’t sure about your corporate name because this is CRUCIAL to getting paid.
By my signature below, for good and valuable consideration (including but not limited to the extension of credit to me), I hereby assign, transfer and convey to __________________________________________(hereinafter “the Provider”) all of my rights, title and interest in and to medical expense reimbursement in whatever form, including but not limited to any automobile liability medical expense payments or other health benefits indemnification and/or agreement otherwise payable to me. This payment shall not exceed my indebtedness to the above named assignee and I acknowledge that I will timely pay any indebtedness owed by me to the assignee that is not otherwise satisfied by the above-mentioned assigned proceeds. I also acknowledge that any medical expenses not covered under my insurance policy will be my responsibility.
I further authorize the Provider to negotiate, collect and settle any claim with any insurance carrier or other third party payor with regard to these services, which authorization shall include authority to:
(1) request and receive from any insurer or any other party any and all documentation and records that I am empowered to request regarding this claim, including, without limitation, a statement of coverage, policy declarations page and insurance policy pursuant to Section 627.4137. In addition, the provider has the authority to request and receive any Independent Medical Examination Reports, notices sent to me regarding appointments for Independent Medical Examinations and Examinations Under Oath (including proof of mail), Records Review Reports, coverage denial letters, Explanations of Benefits, and Benefit Payment Sheets or Logs (P.I.P. Payout Sheets), without regard as to whether such documentation has already been provided to me and,
(2) to endorse in my name any check issued for payment where benefits were assigned. By way of this assignment and notice, I further instruct you, the insurer, to furnish to Provider copies of all future notices affecting Provider’s interest in this claim, including, without limitation, any notices of requested medical examinations or statements.
The Provider hereby objects to any reductions or partial payments. Any partial or reduced payment, regardless of the accompanying language, issued by the insurer and deposited by the provider shall be done so under protest, at the risk of the insurer, and the deposit shall not be deemed a waiver, accord, satisfaction, discharge, settlement or agreement by the provider to accept a reduced amount as payment in full.
I further direct my insurer to direct all payments for services rendered by the Provider directly to Provider at the billing address contained on Provider’s medical bills.
THIS IS A DIRECT AND IRREVOCABLE ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER MY POLICY OF INSURANCE.
A photocopy of this form shall be considered as effective and valid as the original.
I have read the foregoing and understand and agree to each of the above provisions:
Patient’s signature Date